Pediatric Gastroesophageal Reflux Medication
- Author: Steven M Schwarz, MD, FAAP, FACN, AGAF; Chief Editor: Carmen Cuffari, MD more...
A therapeutic response to treatment for gastroesophageal reflux may take up to 2 weeks. If treatment is successful, weight increases and vomiting episodes decrease. Recurrent aspiration pneumonia or apnea is cause for decreased length of medical therapy. Note that the so-called prokinetic agents have been omitted from the following drug list. No currently available prokinetic drug (eg, metoclopramide) has been demonstrated to exert a significant influence on the number or frequency of reflux episodes.
These agents are used as diagnostic tools to provide symptomatic relief in infants. Associated benefits include symptomatic alleviation of constipation (aluminium antacids) or loose stools (magnesium antacids).
Aluminum hydroxide increases gastric pH (>4) and inhibits the proteolytic activity of pepsin, reducing acid indigestion. Antacids can initially be used in mild cases. Aluminum hydroxide has no effect on the frequency of reflux but decreases its acidity.
Magnesium hydroxide is used as an antacid to relieve indigestion. It also causes the osmotic retention of fluid, which distends the colon and increases peristaltic activity, providing a laxative effect. This agent forms magnesium chloride in vivo after reacting with stomach hydrochloric acid.
Histamine H2 Antagonists
Like antacids, these agents do not reduce the frequency of reflux but do decrease the amount of acid in the refluxate by inhibiting acid production. All H2 -receptor antagonists are equipotent when used in equivalent doses. They are most effective in patients with nonerosive esophagitis. H2 -receptor antagonists are considered the drugs of choice for children because pediatric doses are well established and the medications are available in liquid form.
Nizatidine competitively inhibits histamine at the H2 receptor of the gastric parietal cells, resulting in reductions in gastric acid secretion, gastric volume, and hydrogen concentrations.
Cimetidine inhibits histamine at the H2 receptors of gastric parietal cells, causing reductions in gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Ranitidine inhibits histamine stimulation of the H2 receptor in gastric parietal cells, reducing gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Famotidine competitively inhibits histamine at the H2 receptors of gastric parietal cells, reducing gastric acid secretion, gastric volume, and hydrogen ion concentrations.
Proton Pump Inhibitors
These agents are indicated in patients who require complete acid suppression (eg, infants with chronic respiratory disease or neurologic disabilities). Administer proton pump inhibitors with the first meal of the day. Children with nasogastric or gastrostomy tubes may have granules mixed with an acidic juice or a suspension; tubes must then be flushed to prevent blockage.
Lansoprazole suppresses gastric acid secretion by specific inhibition of the H+/K+-adenosine triphosphatase (ATPase) enzyme system (ie, proton pump) at the secretory surface of the gastric parietal cell. The drug blocks the final step of acid production, inhibiting basal and stimulated gastric acid secretion and therefore increasing gastric pH. Lansoprazole's effect is dose related. The drug is easy to administer to children because it is available as a capsule or an oral disintegrating tablet or in granular form for use in an oral suspension.
Omeprazole decreases gastric acid secretion by inhibiting the parietal cell H+/K+-ATPase pump. It is used for the short- and long-term treatment (4-8wk to 12mo) of GERD.
Esomeprazole is an (S)-isomer of omeprazole. It inhibits gastric acid secretion by inhibiting the H+/K+-ATPase enzyme system at the secretory surface of the gastric parietal cells. Esomeprazole is used in severe cases and in patients not responding to H2-antagonist therapy. The drug is administered for up to 4 weeks to treat and relieve the symptoms of active duodenal ulcers; it may be used for up to 8 weeks to treat all grades of erosive esophagitis.
Dexlansoprazole suppresses gastric acid secretion by specifically inhibiting the H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells.
Rabeprazole sodium suppresses gastric acid secretion by specifically inhibiting the H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells.
Pantoprazole suppresses gastric acid secretion by specifically inhibiting the H+/K+-ATPase enzyme system at the secretory surface of gastric parietal cells.
Chao HC, Vandenplas Y. Effect of cereal-thickened formula and upright positioning on regurgitation, gastric emptying, and weight gain in infants with regurgitation. Nutrition. 2007. 23:23-28. [Medline].
Orenstein SR. Management of supraesophageal complications of gastroesophageal reflux disease in infants and children. Am J Med. 2000. 108 (4A):139S-143S. [Medline].
Tolia V, Gilger MA, Barker PN, Illueca M. Healing of Erosive Esophagitis and Improvement of Symptoms of Gastroesophageal Reflux Disease After Esomeprazole Treatment in Children 12 to 36 Months Old. J Pediatr Gastroenterol Nutr. 2015 Jul. 60 Suppl 1:S31-6. [Medline].
Bhatia J, Parish A. GERD or not GERD: the fussy infant. J Perinatol. 2009 May. 29 Suppl 2:S7-11. [Medline].
Rudolph CD. Supraesophageal complications of gastroesophageal reflux in children: challenges in diagnosis and treatment. Am J Med. 2003 Aug 18. 115 Suppl 3A:150S-156S. [Medline].
Gieruszczak-Białek D, Konarska Z, Skórka A, Vandenplas Y, Szajewska H. No effect of proton pump inhibitors on crying and irritability in infants: systematic review of randomized controlled trials. J Pediatr. 2015 Mar. 166 (3):767-70.e3. [Medline].
Henderson D. Proton Pump Inhibitors Do Not Ease Crying, Fussing in Infants. Medscape Medical News. Available at http://www.medscape.com/viewarticle/837588. January 06, 2015; Accessed: June 15, 2015.
Lang JE, Hossain J, Holbrook JT, Teague WG, Gold BD, Wise RA, et al. Gastro-oesophageal reflux and worse asthma control in obese children: a case of symptom misattribution?. Thorax. 2016 Mar. 71 (3):238-46. [Medline].
Mousa H, Woodley FW, Metheney M and Hayes J. Testing the association between gastroesophageal reflux and apnea in infants. J Pediatr Gastroenterol Nutr. 2005. 41:169-177. [Medline].
Gold BD. Gastroesophageal reflux disease: could intervention in childhood reduce the risk of later complications?. Am J Med. 2004 Sep 6. 117 Suppl 5A:23S-29S. [Medline].
Henderson D. Reflux guidelines: modest changes best for most infants. Mescape Medical News. April 29, 2013. [Full Text].
[Guideline] Lightdale JR, Gremse DA. Gastroesophageal reflux: management guidance for the pediatrician. Pediatrics. 2013 Apr 29. e1684-96. [Full Text].
Horvath A, Dziechciarz P, Szajewska H. The effect of thickened-feed interventions on gastroesophageal reflux in infants: systematic review and meta-analysis of randomized, controlled trials. Pediatrics. 2008 Dec. 122(6):e1268-77. [Medline].
Diaz DM, Winter HS, Colletti RB, et al. Knowledge, attitudes and practice styles of North American pediatricians regarding gastroesophageal reflux disease. J Pediatr Gastroenterol Nutr. 2007. 45:56-64. [Medline].
[Guideline] Rudolph CD, Mazur LJ, Liptak JS et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001. 32:S1-S22. [Medline].
Hassall E. Decisions in diagnosing and managing chronic gastroesophageal reflux disease in children. J Pediatr. 2005 Mar. 146(3 Suppl):S3-12. [Medline].
Tucker ME. FDA approves pediatric formulation of proton-pump inhibitor. Medscape Medical News. March 4, 2013. Available at http://www.medscape.com/viewarticle/781615. Accessed: April 2, 2013.
Eisai Inc. FDA approves ACIPHEX Sprinkle (rabeprazole sodium) for use in children ages 1 to 11 [press release]. Available at http://us.eisai.com/view_press_release.asp?ID=129&press=396. Accessed: April 3, 2013.
Rabinowitz SS, Piecuch S, Jibali R, Goldsmith A and Schwarz SM. Optimizing the diagnosis of gastroesophageal reflux in children with otolaryngologic symptoms. Int J Pediatr Otorhinolaryngol. 2003. 167:621-626. [Medline].
Rosen R, Lord C and Nurko S. The sensitivity of multichannel intraluminal impedance and the pH probe in the evaluation of gastroesophageal reflux in children. Clin Gastroenterol Hepatol. 2006. 4:167-172. [Medline].
Diaz DM, Gibbons TE, Heiss K et al. Antireflux surgery outcomes in pediatric gastroesophageal reflux disease. Am J Gastroenterol. 2005. 100:1844-1852. [Medline].
Douglas D. Antireflux surgery benefit not lasting in many children. Medscape Medical News. May 27, 2013. [Full Text].
Gold BD. Outcomes of pediatric gastroesophageal reflux disease: in the first year of life, in childhood, and in adults. J Pediatr Gastroenterol Nutr. 2003. 2003. 37:S33-S39. [Medline].
Mauritz FA, van Herwaarden-Lindeboom MY, Zwaveling S, Houwen RH, Siersema PD, van der Zee DC. Laparoscopic Thal Fundoplication in Children: A Prospective 10- to 15-Year Follow-up Study. Ann Surg. 2013 May 7. [Medline].
Nelson SP, Chen EH, Syniar GM, Christoffel KK. Prevalence of symptoms of gastroesophageal reflux during childhood: a pediatric practice-based survey. Pediatric Practice Research Group. Arch Pediatr Adolesc Med. 2000 Feb. 154(2):150-4. [Medline].
Salvatore S, Hauser B, Vandemaele K. Gastroesophageal reflux disease in infants: how much is predictable with questionnaires, pH-metry, endoscopy and histology?. Journal of Pediatric Gastroenterology and Nutrition. 2005. 40:210-5. [Medline].
Ton M, Suwandhi E and Schwarz SM. Gastroesophageal Reflux. Pediatr Ann. 2006. 35:259-266. [Medline].
Vandenplas Y. Gastroesophageal Reflux : Medical treatment. J Pediatr Gastroenterol Nutr. 2005. 41:S41-S42. [Medline].